Acute Abdomen Thursday, January 24, 2019 1

 Define acute abdomen

 Describe the epidemiology of acute abdomen

 List causes of acute abdomen

 Make diagnosis of different causes of acute abdomen

Acute Abdomen Thursday, January 24, 2019 2

 Acute abdomen

‘‘A clinical syndrome with acute abdominal pain that is severe, localized
and of rapid onset”
(National library of Medicine)
‘’Acute attack of abdominal pain that may occur suddenly or gradually
over a period of several hours and present a symptom complex’’
(S. Das, A manual of clinical surgery: 6th Ed; 337)

 Life-threatening
 Urgent surgical, medical or gynaecological attention
 Early diagnosis & prompt Rx

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 Frequent surgical emergency (worldwide)
 Common cause of admission in patients admitted in emergency
surgical wards (Africa)
 Common emergency condition in general surgery (BMC)
 Age: Neonate- meconeum ileus, Int atresia/stenosis
Infant- intussusception, midgut volvulus
Children- primary peritonitis, appendicitis,NSML
Teenagers- appendicitis, meckel’s diverticulitis
Adult- perorated viscus, cholecystis, acute pancreatitis
Elderly- Sigmoid volvulus, int obst
 Sex: Female- cholecystitis, gyn conditions
Male- sigmoid volvulus, perforated PUD
 Occupation: lead & arsenic industries

Acute Abdomen Thursday, January 24, 2019 4

In Emergency Departments
Nonspecific abdominal pain 40-60%
Gastroenteritis, PID, urinary tract disease 4-24%
Appendicitis, cholecystitis, bowel obstruction

Surgical diagnoses in order of frequency

Appendicitis 15-30%
Cholecystitis 6-9%
Perforated ulcer 2-3%
Bowel obstruction, 2-8%
Pancreatitis. 2-3%

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Congenital
Meconium ileus
Intestinal atresia/ stenosis
Gut malrotation
Congenital bands
CHPS
CIA
CH
AM

Acute Abdomen Thursday, January 24, 2019 6

Abdominal trauma
 penetrating
 blunt
Visceral perforation
 stomach
 duodenum
 ileum
 colon
 gallbladder

Acute Abdomen Thursday, January 24, 2019 7

Visceral obstruction
 intestinal
 Hepatobiliar system
 Urinary tract
Vascular diseases
 dissecting aneurysm
 superior mesenteric occlusion

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Inflammation
 acute appendicitis
 acute cholecystitis
 diverticulitis
 acute pancreatitis
 acute mesenteric adenitis

Acute Abdomen Thursday, January 24, 2019 9

 Ruptured ectopic pregnancy
 Twisted ovarian cyst
 Acute salpingitis
 Tubo-ovarian abscess
 Torsion or degeneration of a uterine fibroid

Acute Abdomen Thursday, January 24, 2019 10

 Primary peritonitis
 Acute AIDS abdomen
 Sickle cell disease-abdominal crisis
 Diabetic ketoacidosis-25% cases
 Uraemic syndrome
 Thoracic conditions
-lobar pneumonia
-diaphragmatic pleurisy
-spontaneous pnuemothorax
 Cardiac diseases
-acute pericarditis
-angina pectoris

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Pain
1. Type- Visceral, parietal, referred.

2. Location- 4 quadrants or diffuse-

(consider individual organ/viscus)

3. Pathogenesis- Mechanical, inflammatory,

vascular

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 stimulation of visceral afferents on distension, contraction,
ischaemia, chemical irritation.
 sympathetic branches of the ANS

 Colicky, diffuse, dull aching, poorly localized and is referred to

cutaneous dermatomes (midline)

 associated with motor and autonomic reflexes [e.g. nausea,

vomiting & reflex hypotension]

 Relieved by pressure

Acute Abdomen Thursday, January 24, 2019 13

 Structure Sensory level Site

Foregut Coeliac(T6-8) Epigastrium

Midgut Sup. Mes(T10-11) Umbilical

Hindgut Inf. Mes (T11-L1)Hypogastrium

Thursday, January 24, 2019 Acute Abdomen 14

 Irritation of parietal peritoneum by blood, inflammatory
exudates, content of hollow viscus e.g. bile, acid, pancreatic
juice
 Constant, sharp, intense and can be localized accurately to the
site of origin

 Information is passed centrally via segmental somatic sensory

nerves

 Aggravated by pressure and movement.

 Associated with reflex rigidity, reduced bowel activity

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  Pain of visceral
disease referred to a
superficial area of
body derived from
the same segment of
cord as the viscus

 ( C- 3, 4, 5) - Diaphragm
 ( T- 7, 8)- biliary
 ( L- 1, 2) - Ureteric

Thursday, January 24, 2019 Acute Abdomen 16

  Location of pain may
suggest organ or
viscus involved and
hence- differential
diagnosis

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 Inflammatory

 Mechanical

 Vascular

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 Peritoneum Primary -Gm +ve: Pneumococcus, Streptococcus
-TB, cirrhosis
Secondary - Spread from other viscera

 Hollow Organs Peptic ulcer, cholecystitis, appendicitis, Meckel’s.

Gastroenteritis (? HIV), diverticulitis

 Solid Organs Pancreatitis, hepatic abscess.

 Mesentery Mesenteric adenitis

 Pelvic Organs PID. tubo-ovarian abscess

Acute Abdomen Thursday, January 24, 2019 19

 Hollow Organs: Int.
obstruction, biliary colic

 Perforated ulcer- e.g. peptic,

typhoid, HIV

 Solid Organs: Acute

hepatomegaly,
splenomegaly.

 Pelvic Organs: Torsion

ovarian tumour

Thursday, January 24, 2019 Acute Abdomen 20

 Hollow Organs: Mesenteric thrombosis, embolus.

 Solid Organs: Rupture liver, spleen. Splenic infarction

 Pelvic Organs: Rupture ectopic, graafian follicle,

uterus, bladder

 Vessel: Rupture of abdominal aortic aneurysm

Acute Abdomen Thursday, January 24, 2019 21

 Lungs: Pneumonia, pleurisy, pulmonary embolism
 Heart: Angina, myocardial infarction, pericarditis.
 Urology: Ureteral calculus, obstructive uropathy,
pyelonephritis, cystitis.
 Neurological: Herpes zoster, spinal cord tumour,
herniated disc
 Vascular: Vasculitis
 Endocrine: Diabetic ketoacidosis, acute adrenal
insufficiency, hyperparathyroidism
 Blood Disorders: Sickle cell crisis, leukaemia, purpura
 Metabolic: Acute porphyria, hyperlipedemia
 Psychogenic: Hysteria
 Toxins: Drugs, poisons, venoms.

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Cc: Abd pain
History of present complaints

Review of system

Gynacological History

Past medical & Surgical History

Family & social history

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 General exam
 Anxious patient lying motionless
◦ Acute appendicitis
◦ Peritonitis

 Rolling in bed and restless

◦ Ureteric colic
◦ Intestinal colic

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 Bending forward
◦ Chronic Pancreatitis

 Jaundiced:
◦ CBD obstruction

 Dehydrated
◦ Temp, Pulse, BP, RR

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 Ruptured Ectopic pregnancy can lead to
◦ Pallor
◦ Hypotension
◦ Tachycardia
◦ Tachypnoea

 Low grade fever can be seen in :-

◦ Appendicitis
◦ Acute cholecytitis

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 High grade fever is seen in:-
◦ Acute Salpingitis
◦ Abscess

 Very high grade fever with increasing lethargy is seen in:-

◦ Peritonitis
◦ Acute Cholangititis
◦ Pyonephrosis

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 Inspection
◦ Scaphoid or flat abdomen PUD

◦ Distended in I.O.

◦ Visible perstalsis in I.O, PS

◦ Any visible masses

◦ cough impulses at hernial site

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 Palpation

◦ hernia sites

◦ Tenderness

◦ Rebound tenderness, Guarding, Rigidity

◦ Local RIF tendernessacute appendicitis, acute

salpingitis in females or amoebiasis of the caecum

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 Low grade poorly localized tenderness-Intestinal obstruction

 Tenderness out of proportion to examination

◦ Mesenteric ischaemia
◦ Acute pancreatitis

 Flank tenderness
◦ Perinephric abscess
◦ Retrocaecal appendicitis

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 Specific clinical signs
◦ Murphy’s sign-acute cholecystitis
◦ Rovsing’s sign-acute appendicitis
◦ Cope’s Psoas sign -retrocaecal appendicitis
◦ Obturator sign -pelvic appendicitis

 Tenderness over the lower ribsinflammation of the

diaphragm, liver, gall bladder or spleen

 Pulsitile abd mass with BPleaking AAA

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 Tenderness
 Induration
 Mass [Blummer’s Shelf
 Frank blood

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 Bleeding
 Discharge
 Cervical excitation test
 Adnexial masses or tenderness
 Uterine size or contour

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 Urine
◦ Urinalysis
◦ Pregnancy test

 Blood
-full blood count
-urea and electrolytes
-liver function test
-serum amylase

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Radiography
-chest radiography
-abdominal radiography

Ultrasound scan

Contrast studies

CTscan

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 Diagnostic peritoneal lavage

 Laparoscopy

 Laparotomy

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 Sigmoidoscopy

 ERCP

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 Definitive treatment depends on:-
◦ Specific disease
◦ General condition of the patient

 Treatment modalities can be:-

◦ Conservative
◦ Surgical

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 Conservative management is indicated in:
◦ Acute cholecystitis
◦ Diverticulitis
◦ Acute PID
◦ Sealed perforations-local peritonitis
◦ Acute pancreatitis
◦ Other medical conditions

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 Surgery is indicated in case of:-
◦ Peritoneal irritation-traditionally an indication for an
emergency operation

◦ Evidence of continuing leakage generalised peritonitis

◦ Failure to respond to non-operative measures

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Acute Abdomen Thursday, January 24, 2019 41
 There may be no
greater opportunity
to alleviate human
suffering and to save
lives than in the
proper evaluation
and treatment of
acute abdomen
conditions.

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